5.1 Occupational Therapy Practice Models & Frames of Reference

Practice Models & Frames of Reference

Core Distinction: An Occupation-Based Practice Model provides an overarching, philosophical lens for conceptualizing the entire human being, their occupational identity, and their dynamic relationship with their environment. A Frame of Reference (FOR) provides specific, operationalized, evidence-based tools, evaluation protocols, and treatment techniques designed to remediate or compensate for specific performance skill deficits.

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|                        THEORETICAL HIERARCHY IN OCCUPATIONAL THERAPY                    |
|                                                                                         |
|  [ LEVEL 1: OVERARCHING PARADIGM & OTPF-4 ]                                            |
|   Core professional philosophy: Occupation is central to health, well-being, & identity |
|                                  │                                                      |
|                                  ▼                                                      |
|  [ LEVEL 2: OCCUPATION-BASED PRACTICE MODELS ] (Holistic / Broad Lenses)               |
|   * MOHO (Volition, Habituation, Performance Capacity, Environment)                     |
|   * PEOP (Person, Environment, Occupation, Performance Interactions)                    |
|   * CMOP-E (Spirituality at core, Person, Environment, Occupation/Engagement)           |
|   * OA (Desire/Demand for Mastery, Adaptive Capacity, Relative Mastery)                 |
|                                  │                                                      |
|                                  ▼                                                      |
|  [ LEVEL 3: FRAMES OF REFERENCE (FORs) ] (Mechanistic / Specific Action Tools)          |
|   * Remedial / Restorative: Biomechanical, NDT, PNF, Motor Learning, Ayres SI          |
|   * Compensatory / Adaptive: Rehabilitative FOR, Allen Cognitive Disabilities Model     |
|   * Psychosocial / Behavioral: Cognitive-Behavioral Frame of Reference (CBT)            |
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Top Occupation-Based Practice Models

Occupation-based models guide the occupational therapist in structuring the occupational profile, synthesizing assessment data, and framing client-centered goals.

1. Model of Human Occupation (MOHO)

Developed by Gary Kielhofner, MOHO posits that humans are open systems dynamically interacting with their environment. Occupational engagement is driven by three interrelated internal subsystems:

• Volition (The Motivation for Occupation):
  • Personal Causation: A client's sense of personal capacity and self-efficacy ("Am I capable of doing this?").
  • Values: Beliefs, commitments, and moral standards about what is good, right, and important ("Is this worth doing?").
  • Interests: What one finds enjoyable, satisfying, or engaging ("Do I like doing this?").
• Habituation (The Organization of Daily Patterns):
  • Habits: Automated routines, behavioral tendencies, and typical ways of performing daily tasks without conscious effort.
  • Roles: Socially defined identities and behavioral expectations (e.g., parent, worker, student, volunteer, spouse).
• Performance Capacity (Underlying Abilities & Lived Experience):
  • Objective Components: Physical, cognitive, and sensory-motor systems (musculoskeletal, neurological, cardiopulmonary).
  • Subjective "Lived Body" Experience: How the person subjectively experiences their physical and mental functioning from within.
• Environment: Physical spaces, objects, occupational forms, and social groups that provide affordances, demands, and constraints.
• Key MOHO Outcomes: Building Occupational Identity (who one is and wishes to become) and Occupational Competence (the ability to sustain patterns of occupational participation consistent with one's identity) leading to Occupational Adaptation.

2. Person-Environment-Occupation-Performance (PEOP) Model

Developed by Christiansen, Baum, and Bass, PEOP is a transactional, system-based ecological framework that emphasizes the dynamic intersection of four distinct elements:

                     ┌────────────────────────────────────────┐
                     │       PEOP TRANSACTIONAL ENGINE        │
                     └───────────────────┬────────────────────┘
                                         │
         ┌───────────────────────────────┴───────────────────────────────┐
         ▼                                                               ▼
┌────────────────────────────────┐                             ┌────────────────────────────────┐
│       PERSON (Intrinsic)       │                             │     ENVIRONMENT (Extrinsic)    │
│ * Physiological (health/pain)  │                             │ * Culture & Values             │
│ * Psychological (affect/mood)  │                             │ * Social Policy & Systems      │
│ * Cognitive (memory/attention) │                             │ * Social Support & Capital     │
│ * Neurobehavioral (sensory)    │                             │ * Physical & Built Spaces      │
│ * Spiritual (meaning-making)   │                             │ * Assistive Technology         │
└────────────────┬───────────────┘                             └────────────────┬───────────────┘
                 │                                                              │
                 └───────────────────────────────┬──────────────────────────────┘
                                                 ▼
                                ┌─────────────────────────────────┐
                                │     OCCUPATION (Activities,     │
                                │     Tasks, Roles of Daily Life) │
                                └────────────────┬────────────────┘
                                                 ▼
                                ┌─────────────────────────────────┐
                                │    OCCUPATIONAL PERFORMANCE     │
                                │        & PARTICIPATION          │
                                └─────────────────────────────────┘

• Core Premise: Occupational performance and well-being only occur when intrinsic person factors and extrinsic environmental systems harmonize with meaningful occupational tasks.
• Assessment & Intervention Focus: Modifying environmental barriers (e.g., removing architectural obstacles) or supporting intrinsic capacities to optimize participation in valued life roles.

3. Canadian Model of Occupational Performance and Engagement (CMOP-E)

Developed by Townsend and Polatajko, the CMOP-E is visually depicted as a three-dimensional sphere emphasizing that occupational participation extends beyond physical execution to encompass Occupational Engagement.

• Spirituality at the Core: Spirituality is conceptualized as the central essence of the person—the core of meaning, purpose, selfhood, and choice. It resides at the very center of the model.
• Person (Surrounding Core): Encompasses Cognitive, Affective (emotional), and Physical components.
• Occupation: Categorized into three universal domains: Self-Care, Productivity, and Leisure.
• Environment: Encapsulates the outer boundary across four spheres: Physical, Cultural, Institutional (legal/economic/healthcare policies), and Social.
• Engagement Concept: Individuals can be meaningfully engaged in occupations even if they do not physically perform the motor actions themselves (e.g., directing one's personal care attendant).

4. Occupational Adaptation (OA) Model

Developed by Schkade and Schultz, OA is an internal normative process where occupation serves as the primary medium for human adaptation.

• The Press for Mastery:
  • The Person has an internal Desire for Mastery.
  • The Occupational Environment asserts an external Demand for Mastery.
  • When the person engages in an occupational challenge, these forces generate the Press for Mastery.
• Adaptive vs. Dysadaptive Responses: When encountering a barrier, an individual generates an adaptive response (flexible, novel problem-solving) or a dysadaptive response (rigid, perseverative, or avoidant behaviors).
• Relative Mastery: The client evaluates their own occupational performance across four specific metrics:
  1. Efficiency: Was the use of physical, cognitive, and temporal energy optimal?
  2. Effectiveness: Was the intended occupational goal successfully accomplished?
  3. Self-Satisfaction: Does the client feel personal pride and fulfillment in their performance?
  4. Societal Satisfaction: Does the performance satisfy external social and environmental expectations?
• Therapeutic Focus: The primary goal in OA is not merely training an isolated splinter skill, but rather re-establishing the client's internal adaptive capacity so they can independently navigate future occupational challenges.

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Major Frames of Reference (FORs)

Frames of reference provide concrete theoretical rationales and specific techniques for evaluation and intervention.

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|                                 FOR CLINICAL SPECTRUM                                   |
|                                                                                         |
|   RESTORATIVE / REMEDIAL PARADIGM              COMPENSATORY / ADAPTIVE PARADIGM         |
|   (Assumes remediation potential)              (Assumes residual/fixed deficits)        |
|                                                                                         |
|   * Biomechanical FOR                          * Rehabilitative FOR                     |
|   * Motor Learning / Task-Oriented             * Allen Cognitive Disabilities Model     |
|   * Neurodevelopmental Treatment (NDT)         * Ergonomic / Environmental Adaptation   |
|   * Proprioceptive Neuromuscular Fac. (PNF)                                             |
|   * Ayres Sensory Integration (ASI)                                                     |
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1. Biomechanical Frame of Reference

• Core Principles: Applies principles of physics, kinetics, kinematics, anatomy, and exercise physiology. Focuses on structural stability, joint Range of Motion (ROM), muscle strength, physical endurance, and tissue healing.
• Fundamental Assumptions: The central nervous system is intact; musculoskeletal and peripheral nerve deficits are remediable through targeted exercise, active stretch, and physical stress adaptation.
• Key Interventions: Progressive resistive exercise (PRE), active/passive stretching, joint mobilization, goniometric tracking, physical agent modalities (PAMs), and activity grading to restore physical capacity.

2. Rehabilitative / Compensatory Frame of Reference

• Core Principles: Focuses on facilitating functional independence despite persistent, non-remediable impairments or permanent physical/cognitive deficits.
• Key Interventions: Environmental modifications (ramps, grab bars), adaptive equipment (reachers, sock aids, button hooks), compensatory strategies (one-handed dressing techniques, visual scanning checklists), energy conservation, work simplification, and wheelchair seating systems.

3. Neurodevelopmental Treatment (NDT / Bobath)

• Core Principles: A hands-on sensorimotor approach developed by Berta and Karel Bobath for upper motor neuron lesions (e.g., CVA, TBI, Cerebral Palsy). Focuses on restoring normal movement patterns and functional motor control.
• Key Mechanisms:
  • Key Points of Control: Placing the therapist's hands at proximal points (head, trunk, scapula, pelvis) or distal points (hands, feet) to guide movement.
  • Inhibition: Inhibiting abnormal muscle tone, spastic synergy patterns, and primitive postural reflexes.
  • Facilitation: Facilitating normal righting and equilibrium reactions, active weight-bearing, postural alignment, and coordinated bilateral movement.
  • Avoidance of Compensations: Strongly discourages abnormal one-handed compensatory movement until bilateral restorative potential is maximized.

4. Proprioceptive Neuromuscular Facilitation (PNF)

• Core Principles: Developed by Herman Kabat, Margaret Knott, and Dorothy Voss. Utilizes mass movement spiral and diagonal patterns that mimic functional human movement, recruiting multiple muscle groups across planes.
• Key Mechanisms:
  • Diagonal Patterns (D1 and D2):
    • D1 Flexion (Upper Extremity): Shoulder flexion, adduction, external rotation (e.g., bringing food to the mouth or combing hair on opposite side).
    • D1 Extension (Upper Extremity): Shoulder extension, abduction, internal rotation (e.g., pushing off a chair armrest during sit-to-stand).
    • D2 Flexion (Upper Extremity): Shoulder flexion, abduction, external rotation (e.g., drawing a sword and reaching up into high cabinet on same side).
    • D2 Extension (Upper Extremity): Shoulder extension, adduction, internal rotation (e.g., buttoning pants on opposite hip or sheathing a sword).
  • Irradiation / Overflow: Stronger muscle groups transfer motor excitation to weaker synergists.
  • Techniques: Rhythmic Initiation (passive to active-assistive to active-resisted), Contract-Relax, Hold-Relax, and Slow Reversals.

5. Ayres Sensory Integration (ASI)

• Core Principles: Developed by A. Jean Ayres. Emphasizes that neurobiological processing and integration of sensory inputs (vestibular, proprioceptive, tactile, visual, auditory) form the foundation for motor planning (praxis), emotional regulation, and academic learning.
• Key Mechanisms:
  • Sensory Modulation: The brain's ability to regulate responses to sensory stimuli (addressing sensory over-responsivity, under-responsivity, or sensory craving).
  • Praxis: The tripartite process of Ideation (generating an idea), Motor Planning (sequencing actions), and Execution (performing the motor act).
  • Adaptive Response: A purposeful, goal-directed response to a sensory experience that masters an environmental challenge.
  • The Just-Right Challenge: Structuring therapeutic activities that challenge the child's sensory and motor systems without overwhelming them.

6. Allen Cognitive Disabilities Model (CDM)

• Core Principles: Developed by Claudia Allen. Posits that cognitive performance is biologically determined by brain physiology and cannot always be remediated in progressive or severe neurocognitive disorders.
• The 6 Cognitive Levels:
  • Level 1: Automatic Actions (Bedridden, responds to subliminal internal cues, reflex actions).
  • Level 2: Postural Actions (Movement in response to proprioceptive cues, gross body movements, imitation of posture).
  • Level 3: Manual Actions (Uses hands to manipulate tactile objects, repetitive actions, lacks goal-directed intent, requires tactile cues).
  • Level 4: Goal-Directed Actions (Completes familiar multi-step routines, relies heavily on visual cues, unable to anticipate errors, cannot learn from written instructions without live demo).
  • Level 5: Exploratory Actions (Trial-and-error problem solving, inductive reasoning, learns new multi-step tasks with physical practice, lacks anticipatory foresight/hazard awareness).
  • Level 6: Planned Actions (Hypothetical-deductive reasoning, anticipatory error prevention, understanding abstract concepts, fully independent).
• Assessment & Clinical Goal: Evaluated using the Allen Cognitive Level Screen (ACLS-5); treatment emphasizes modifying tasks, providing appropriate environmental cues, and educating caregivers to match the client's current functional level.

7. Cognitive-Behavioral Frame of Reference (CBT / CB-FOR)

• Core Principles: Focuses on the relationship between thoughts (cognitions), feelings (affect), and actions (behavior). Maladaptive behaviors stem from automatic thoughts and cognitive distortions.
• Key Interventions: Cognitive restructuring (identifying cognitive distortions like catastrophizing), self-monitoring thought logs, graded activity scheduling, behavioral activation, systematic desensitization, and coping skills training.

8. Motor Learning & Task-Oriented Approach

• Core Principles: Grounded in dynamic systems theory; motor control emerges from the interaction among the person, task demands, and environmental context. Emphasizes active, goal-directed practice of functional tasks.
• Key Practice Structures & Feedback:
  • Practice Schedules: Blocked practice (repetitive single task; enhances immediate acquisition) vs. Random practice (variable task sequence; optimizes long-term retention and motor transfer).
  • Practice Distribution: Massed practice (rest period < practice time) vs. Distributed practice (rest period $\ge$ practice time; prevents fatigue).
  • Feedback Mechanisms: Knowledge of Results (KR) (outcome feedback, e.g., "You spilled 2 ounces of water") vs. Knowledge of Performance (KP) (movement quality feedback, e.g., "Keep your elbow tucked against your ribs").
  • Feedback Timing: Fading feedback and summary feedback promote internal error detection and prevent feedback dependency.

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Clinical Decision Matrix: Matching Clinical Profiles to Models and FORs